Endoscopy and the Gastrointestinal Cancer Patient

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Endoscopy procedures are an integral part of the diagnosis, treatment, and management of gastrointestinal cancer patients. The endoscopy nurses and technicians are often the first medical providers whom gastrointestinal cancer patients come into contact with when a diagnosis of cancer is made. Understanding the role of endoscopy in cancer care, and coordinating with other medical professionals involved, will improve the patient’s overall experience and maximize his/her ability to cope with their diagnosis. This article will review three common forms of gastrointestinal cancer, discuss the use of endoscopic procedures in the diagnosis and treatment of these cancers, and provide insight on how the endoscopy nurses and technicians can assist cancer patients and the other medical professionals caring for them.

Overview of Gastrointestinal Cancer

Gastrointestinal cancers combined comprise the largest group of new cancers diagnosed in 2007.1 They include cancers of the esophagus, stomach, small intestine, colon, rectum, anal canal, liver, pancreas, gallbladder and biliary system. Although all of these cancers occur in the gastrointestinal tract, they have very different presentations, treatments and survival patterns. Endoscopic procedures play a role in the diagnosis, staging, and management of all these cancers.

All common gastrointestinal cancers are staged using the T (tumor size and extent), N (number of lymph nodes involved with cancer), M (distant metastasis to other organs) staging system as delineated by the American Joint Committee on Cancer.2 The TNM staging is used as a guide for prognosis for the patient, and to assist medical professionals in making treatment decisions. It is often translated into Stages I-IV utilizing the TNM data. Patients with earlystage disease have a better prognosis than those with locally advanced (T3 of above) or metastatic disease (designated as an M1 or stage IV). Radiological exams are used in all these cancers to assist in staging of the cancer, and determine the surgical resectability of cancerous tumors.

Esophageal Cancer

Cancers can arise anywhere along the passage that connects the mouth to the stomach, and are usually either a squamous cell carcinoma or an adenocarcinoma. In the United States, adenocarcinoma is the more common esophageal histological subtype. The symptoms associated with esophageal cancer include difficulty swallowing, weight loss, cough especially induced when swallowing, pain when swallowing, and — less likely — hoarseness. The disease is often diagnosed with direct endoscopic visualization and biopsy. Accurate staging for surgical intervention often involves endoscopic ultrasound for tumor depth and lymph node involvement. Bronchoscopy is often done when the tumor is in the upper to mid-esophagus or if it is of squamous histology. This is to ensure that the trachea is not invaded by the tumor. The five-year survival rate varies from greater than 70 percent in stage 1 tumors to almost zero in stage IV (metastatic tumors). Unfortunately, due to the location and nature of these tumors, patients are often not diagnosed till they are at a very late stage. Treatment is dependent on the stage and often includes surgery and chemotherapy.3

Gastric Cancer

These cancerous tumors arise anywhere from the gastroesophageal junction to the pylorus, and occur more often in men than women. These cancers are often found in a late stage with patients presenting with abdominal pain, lack of appetite, weight loss, or complaints of fatigue. Patients may have anemia, hematemesis (bloody vomitus), and/or melena (black, tarry stools). Diagnosis of the cancer is often done with endoscopy and biopsy to determine the histological subtype, with 95 percent of cases being adenocarcinomas. Endoscopic ultrasound is also used in gastric cancer to stage the tumor and evaluate for resectability. Treatment modalities include surgery, chemotherapy, and radiation and are dependent on the stage of disease.4

Colon and Rectal Cancer

These cancers can present anywhere along the large bowel or rectum, and there is a higher incidence of the disease in the United States and Western Europe. This is thought to be due to diet and environmental factors. The signs and symptoms of the disease depend on the location of the tumor within the gastrointestinal tract, but can be vague and difficult to interpret. Right-sided colon cancers can cause vague abdominal aching, anemia from chronic blood loss, weakness, weight loss, and possibly a palpable abdominal mass. Tumors arising on the left side of the colon often cause constipation alternating with diarrhea, abdominal pain, and possible obstructive symptoms such as nausea and vomiting. There may be visible blood in the stool. Rectal tumors often present with a change in the stool, including a narrowing of the stool caliber, rectal fullness, tenesmus, fecal urgency and bright red blood in the stool.

Endoscopic exams, including colonoscopy, are the gold standard for diagnosing the disease. In early-stage lesions, the endoscopic removal of the tumor is the treatment of choice. This is feasible if the tumor is confined to a polyp that is completely excised endoscopically.5 Colon cancer is staged surgically if there is no evidence of metastatic disease, while rectal cancer is now staged clinically with endoscopic ultrasound to evaluate the size of the tumor and local lymph nodes. Current recommendations state that any T3 or N1 or above rectal cancer should have preoperative radiation and chemotherapy to locally reduce the size and involvement of the tumor. Localized colon cancer or rectal cancer that is adequately treated can have very high survival rates, especially if the tumor was confined to the bowel wall.6 However, recent data has shown that even some patients who have colon cancer with metastatic disease to another organ can be treated with chemotherapy and surgical resection with intention to cure. This is a huge advance, as the previous life expectancy for metastatic colon cancer was six months with the best supportive care.7

Case Study of the Many Uses of Endoscopy in the Gastrointestinal Cancer Patient

Bill Taylor (not his real name) is a 67- year-old gentleman who presented to his primary care doctor with a three-month history of rectal bleeding and a one-month history of rectal spasms. His primary care doctor feels a mass and refers him for an endoscopic evaluation. He comes to the endoscopy center with his wife and grown son. He is prepped using common cathartics starting the day before. He is sedated and undergoes a colonoscopy. The cecal strap is identified and then the entire colon is evaluated. The prep is good, and in the rectum, a 2 cm raised, friable mass is found 10 cm from the anal verge. It is biopsied and found to be positive for adenocarcinoma.

The patient then undergoes a CT scan of the chest, abdomen, and pelvis to ensure there are no distant metastases. The scans are clear (M0), and he is sent back to the center for a transrectal endoscopic ultrasound for staging of the local tumor. He is found to have a tumor extending into the muscularis propria, but not through the bowel wall (T2), with no enlarged local lymph nodes (N0). He is found to be a surgical candidate and goes on to have a low anterior resection. The tumor is pathologically confirmed as a T2N0, meaning that the tumor was not penetrating through the bowel wall, and there were no local lymph nodes involved. Twenty lymph nodes are sampled and sent to pathology for examination with the primary tumor specimen.

He undergoes follow-up with a medical oncologist. He has localized disease and opts to follow a close surveillance approach, which includes yearly colonoscopies for the first three years after the surgical resection. Unfortunately, in the second year of surveillance, his colonoscopy shows a recurrence at the anastomotic site (where the colon and rectum were surgically rejoined). He again undergoes a transrectal ultrasound, and is found to have many local lymph nodes involved with tumor). Now he undergoes local radiation and combination chemotherapy for two months, and than undergoes an abdomino-perineal resection, with diverting colostomy.8 His tumor was large and extended into the prostate, which was removed as well (T4 ), and was found to include 10 local lymph nodes (N2). After his surgery, he completes four months more of chemotherapy.

A year later, he is found to be jaundiced, and undergoes an endoscopic retrograde pyloregram with biopsy, and strictroplasty of the biliary system. A plastic stent is placed to drain the biliary system and alleviate the obstruction of common bile duct.9 The biopsy reveals metastatic moderately differentiated adenocarcinoma morphologically identical to the rectal primary. He is then referred back to his oncologist for further chemotherapy. On CT scan, he is found to have one lesion in the right lobe of the liver. He undergoes two months of chemotherapy and the lesion shrinks. He then undergoes liver resection, and completes four more months of chemotherapy.10 He now returns for annual surveillance, and recent colonoscopy reveals one adenomatous polyp. As seen above, the endoscopy nurse has many points of contact with the gastrointestinal cancer patient. Each point comes with a different set of expectations and fears for patients, family members and friends. The endoscopy nurse can intervene to provide information and support to these patients at each contact point.

Coordination of Care

A vital role for the endoscopy nurse is the coordination of care between multiple specialists. There are often primary care doctors, internal medicine doctors, gastroenterologists, oncologists, and surgeons involved in the care of the cancer patient. With multiple specialists, the chance for confusion and lack of coordination abounds. The nurse needs to ensure that the reason underlying the to exam is clear both to the patient and to the provider of the endoscopic exam. This includes a history of patient illnesses and prior diagnoses, as well as current therapies. The endoscopy nurse also needs to be an advocate for a timely communication system to the referring physician, as well as other specialists involved in the cancer patient’s care, with regards to endoscopic findings. Patients with advanced cancer often face symptom distress that could be alleviated by clear communication between the various specialists. An example of this is a patient with carcinomatosis (widespread abdominal metastases) from colon cancer. After multiple readmissions for nausea, vomiting and small bowel obstruction, the decision is made in consult with the gastrointestinal oncology service to place a decompression G-tube. The reason is clearly documented and the proper gastrostomy tube is chosen to ensure that suction can be used to decompress the stomach. This allows the patient to return home comfortably to be with his family.

Psychosocial Support of the Gastrointestinal Cancer Patient

Being diagnosed with cancer is often one of the most stressful experiences a patient can have. The task-based model of life-threatening illness groups the tasks of illness into five phases. Knowledge of these phases gives the nurse a guide to providing psychosocial support to their patients. The phases include the pre-diagnostic phase, when the individual recognizes symptoms or risk factors for an illness, which often lead to diagnostic testing. Next is the acute phase, during which the patient has to learn about the disease and make decisions regarding care and treatment. The chronic phase occurs when the patient is undergoing the treatment and dealing with the side effects. The patient may then move on to recovery, when they will need to deal with the many sequelae related to recovery from the previous disease and treatment. Individuals with life-threatening disease may go on to a terminal phase of illness, when their death from the cancer is inevitable.11

In the pre-diagnostic phase, giving the patient information regarding the testing and possible after-effects and follow-up care can help reduce stress. Also, the nurse should stress the importance of following up with the referring physician with regard to biopsies and pathology results. This ensures that the patient receives information in a timely way to reduce stress and anxiety. In the acute phase of the illness, provide the patient information to make decisions. This includes referrals to support groups such as the American Cancer Society, the local Wellness Community, or other local groups. A study has shown that patients who underwent psychotherapeutic support at the time of surgery for their gastrointestinal cancer had a statistically significant higher survival rate when compared to those who received no psychotherapeutic support.12 Simply by referring the newly diagnosed cancer patient to receive support, the nurse could improve the patient's survival chances.

During the acute phase of the illness, the endoscopic nurse may be involved in assisting in the management of treatment-related symptoms or assessing treatment response. This would include doing an endoscopy on an esophageal cancer patient who is undergoing pre-operative chemotherapy and is having swelling and bleeding of the tumor within the esophageal lumen. This could also include an endorectal ultrasound for restaging after chemotherapy and radiation. Providing factual information about the exam and its findings to the patient and their family can help reduce anxiety. Also, to alleviate the patient's stress, be supportive of the many challenges faced by the patient and family while undergoing intensive cancer treatment, and convey empathy.

During the recovery phase, providing empathy for the stress that family and patients feel while undergoing surveillance exams can improve the patient’s experience with, and adherence to, follow-up scopes. During the terminal phase, palliating symptoms such as biliary or gastric obstruction can add comfort and quality to the final days and months of the cancer patient’s life.

Conclusions

There are many roles for endoscopy in managing patients with gastrointestinal cancer, and these roles are expanding daily. Gastrointestinal cancer patients are provided endoscopic options that improve diagnosis, staging, treatment and palliation. Understanding the importance of good coordination of care, and paying attention to patient needs and fears, will improve patient care outcomes.

Marie Christine M. Seitz, RN, NP-BC, AOCN, is a nurse practitioner in the gastrointestinal oncology program at USC/Norris Cancer Center.


Free Resources

There are many free resources available for cancer patients. For example, one nonprofit organization offers cancer workout centers in some cities. These centers offer customized exercise programs for cancer patients who are currently in treatment or finished with their treatment.

For many patients, cancer treatment can be financially as well as emotionally devastating; insurance rarely covers the cost of caregivers, and patients must frequently reassess careers in the face of side effects that include fatigue, depression, and impaired immunity. Most oncologists know that published medical literature demonstrates clear benefits from moderate exercise, but few can prescribe this exercise solution because most communities lack a program that is both effective and inexpensive.

The Cancer Workout Center of Phoenix™ (CWC) is a leader in the effort to change this. Founders Jamie Meyers and Suzy Wilke are personal trainers who recognized the need and created a collaborative model that unifies oncologists, patients, and community centers to bring new hope and new energy to survivors.

CWC offers free, 10-week classes that focus on increasing strength, flexibility and endurance. Meyers and Wilke teach survivors Cancer WellFit™, a program developed in 1993 by an exercise physiologist and a breast cancer survivor in conjunction with the Santa Barbara Medical Center. Each participant receives individual instruction in exercise and nutrition. “People can start anytime, and after 10 weeks, survivors have acquired the skills and experienced the benefits of making exercise part their recovery and their new life,” Wilke explains.

The American Cancer Society also offers many free services to cancer patients and their families. These include free transportation to medical appointments, housing, medical equipment and supplies, and financial assistance for burial, clothing, and other emergency needs.


New Cancer Treatments

Some companies are offering new products to facilitate treatment that may have been impossible with older technology.

For example, IntraOp Medical Corporation has a unique device, Mobetron, that enables patients with the most aggressive forms of cancer to receive treatments that can extend their lives. With the Mobetron, radiation and surgical oncologists can pinpoint the exact area that requires radiation and immediately deliver high doses directly to the affected tissue during cancer surgery.

Mobetron uses intraoperative electron-beam radiation therapy (IOERT), a more precise form of intraoperative radiation therapy (IORT) that provides more uniform dose distribution, less toxicity, quicker treatment and proven clinical outcomes.

Mobetron is an electron-beam linear accelerator. Because it is self-shielding, it can be used in any operating room, which could not be done with previous versions of this type of radiation. In earlier technology, operating rooms had to be retrofitted to protect staff members from radiation, or be installed in the hospital basement where it could be well shielded.

“This device can deliver radiation at the time of surgery by allowing the surgeon to place healthy tissue aside and focus electron beam radiation on the microscopic residual cancers that are left,” says Donald A. Goer, PhD, president and CEO of IntraOp Medical Corporation. “Before this model became available, this type of radiation was only available from conventional accelerators, which weighed 18,000 pounds and required 100 pounds of shielding, so it was often placed in the basement. Mobetron provides the same radiation, but weighs only 2,700 pounds and requires no modification to the OR.

“One advantage of intraoperative electron-beam radiation therapy is that, when the surgeon says he got it all, there’s always a chance of microscopic residual cancer within the site. That’s why they send the patient for post-op radiation,” Goer concludes.

In normal radiation treatment, radiation targeted at the tumor site is administered over several weeks, via an external source that must penetrate the patient’s skin and surrounding organs to reach the tumor, Goer points out. “As radiation passes through the body, the radiation beam is absorbed at different concentrations and can potentially damage the surrounding tissue.”

But IOERT is administered during surgery, while surrounding healthy tissue can be moved out of the path of the beam, allowing a larger dose of radiation to be delivered directly to the tumor bed. It’s directed, reduces damage to healthy tissue, and enables a larger dose while reducing the side effects that would be the result of a more systemic delivery. And, Goer adds, “It doesn’t give local cancerous cells time to reconstitute and spread.”

The Mobetron device is being used to treat multiple types of cancer, including esophageal, hepatobiliary, pancreatic, rectal, retroperitoneal, and gastric cancers.

References:

1. Cancer Facts and Figures – 2007, American Cancer Society (ACS), Atlanta, Georgia, 2007.
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3. Paz, IB, Hwang, JJ, & Iyer, VI. “Esophageal Cancer.” 251-71, in Cancer Management: A Multidisciplinary Approach. edited by Richard Pazdur, Lawrence R. Coia, William Hoskins, and Lawrence Wagman. 2007.
4. Blanke, CD, Coia, LR, & Schwarz, RE. “Gastric Cancer.” 273-286, in Cancer Management: A Multidisciplinary Approach. edited by Richard Pazdur, Lawrence R. Coia, William Hoskins, and Lawrence Wagman. 2007.
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9. Kaassis M, et al. Plastic of metal stents for malignant stricture of the common bile duct? Re-sults of a randomized prospective study. Gastrointestinal Endoscopy. 57(2): 178-82, Feb 2006.
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